Americans With Disabilities Act Plan

Please fill out this form completely. Sign and submit at the bottom of this page.

If you are unable to complete this form due to a disability or need additional information, please contact the ADA Coordinator at 423.753.1031 for assistance and the Town, to the extent possible, will make reasonable accommodations.

Confidentially:
Information contained on this form will be classified as CONFIDENTIAL to the extent permitted by law. Information obtained or generated in the processing of the accommodation request may be released to individuals of Town departments or agencies participating in the evaluation or provision of the accommodation requested.

Complainant:

Person Discriminated Against (if other than the Complainant):

Name

Address

Phone Number

Name

Address

Phone Number

Town Department, Facility, Program or Employee which you believe has discriminated or has an accessibility issue:

Date the discrimination occurred

Time discrimination occurred

Describe the acts of discrimination providing the name(s) where possible of the individuals who discriminated

If there is an ADA access issue, please describe in detail the concern and location

Have you previously submitted an "Accommodation Request Form?

Date previously submitted

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